Optimizing Capital Investments in Health Facilities through Prototype Development & Simulation Evaluations Prior to Implementation

Optimizing Capital Investments in Health Facilities through Prototype Development &

Simulation Evaluations Prior to Implementation

March 15, 2010

Speakers

Dale E. Beatty, MSN, RNExecutive Vice President Patient Services & Chief Nursing Officer Northwest Community Hospital

Deborah Sheehan, ACHE,EDAC, LEED AP

PrincipalCannon Design

Jocelyn Stroupe, AAHID, IIDA, ASID, EDACPrincipalCannon Design

Charlie Stevenson, AIA, CPE

DirectorNorthwest Community Hospital

Building Healthcare facilities without re-engineering the operational model can be risky and often is unsuccessful

Prototyping tools can enhance the ability to meet current healthcare needs quickly and effectively through the use of proven techniques that test theories related to positive outcomes

Healthcare facilities are challenged to continually deliver care with fewer resources. The simulation and prototype process assists in prioritizing value based decisions and can enable the care model to be developed in a low-risk environment

Key Issues

Agenda: Prototype Development

What can be the impact of Prototype application?

Outcomes of Prototype Development

Prototype as Process Standard;

Clinical Protocols, Workflow Patterns, Technology Applications

Prototype as Physical Standard;

Department Organization, Key Rooms, Product Specifications

Impact of Prototype Application

Research Applied To Prototype Development

Metrics Benchmarking

Clinical Measures

Environment Impact

Measures

Satisfaction Measures

Financial Measures

Impact of Prototype Applications

Metrics Benchmarking

Clinical Measures

Environment Impact

Measures

Satisfaction Measures

Financial Measures

Prototype Development

Process Protocols/Standards

Safety and Outcome Improvements

Medication Errors, Falls, Time to Treatment

Willingness to Recommend Score >85%

NPV Results

Operating Costs, Program Size, Time to Market

Outcomes of Prototype Development

Clinical Measures Benchmarking Clinical Pathway and Workflow Design

Supplies16%

Insurance3% Capital

10%

Staffing Resources71%

Clinical Measures Benchmarking Clinical Pathway and Workflow Design

AmbulatoryPatient

AmbulancePatient

Greeting/Triage

Diagnostics

Non-Urgent

NursingUnitCashier AdmitDischargeHome

Decontam

Non-Contam

Visual Barrier

ClinicalDecision

Unit

OtherFacility/NursingHome

Transfer

Observe

Admit

Transfer

HomeDischarge

Admit

Major ED Rooms/

Trauma

Radiography

In Room• Admit• Lab• RT• EKG

Exam/Treatment

Room

In Room• Admit• Lab• RT• EKG

Emergency

Published Studies on Evidence-Based Design1200

600

84

1998 2004 2008

Environment Impact Measures Application of Evidenced Based Design

Financial Measures Impact to First and Lifecycle Cost

118.2 KBtu/SF at $.08/kWh

= $ 901,244 Annual energy cost

Financial Measures Impact to First and Lifecycle Cost

48 kBtu/sf at $.08/kWh

= $ 360,500 Annual energy cost

Yield Savings of $ 540,000 per year

@ 4% margin= $10M Revenue

Financial Measures Impact to First and Lifecycle Cost

PHAMA: Establishing the Business Case

Patient and Staff Satisfaction MeasuresTarget Top Quartile in All Areas

Inpatient Likelihood to Recommend   99th%tile

Outpatient Likelihood to Recommend  50th %tile

Emergency Department  Likelihood to Recommend   92 %tile

1st fy Q 10 2nd fy Q 10 3rd fy Q 10 4th fy Q10 1st fy Q110

10

20

30

40

50

60

70

80

90

Patient Satisfaction per Quarter / Year

Series1

Quarter / Year

Per

cen

tile

Ran

k

Prototype as Process Standard;

Clinical Protocols, Workflow Patterns, Technology Applications

Prototype Development: An Illustrative Model

Northwest Community Healthcare (NCH)

Evidence-based decision process–Rigorous Benchmarking–Ongoing ROI Analysis– Research to validate Key Assumptions

– Medication Distribution– Family Care Model– Established Performance Metrics

clinical, consumer, operations, financial

–Product life cycle analysis–Energy Consumption modeling

NCH Strategic Goals

1 Move from semi-private patient rooms to private rooms to meet consumer demand

2 Position hospital to adapt to a variety of acuity levels of patients easily with minimum construction disruption

3 Speed to market: competitive environment

Staff / Consumers / Technology

4 Achieve regulatory and clinical advancements

Need to convert patient population a staff neutral cost model

Apply standardization of patient units design for ease of adaptation / conversion in future

Universal size of planning module allow for prefabrication & testing of repetitive units off site

Innovate and standardize clinical protocols for medication distribution at bedside

Prototype Opportunity

Applied a model for assessing health care quality based on structure, processes and outcomes developed by Dr. Avedis Donabedian

First Step in Creating PrototypesAssess Model of Care

Structures Processes

CONSEQUENCE of the

healthcare provided

METHOD by which

healthcare provided

ENVIRONMENT in which

healthcare provided

Outcomes

StructuresPrototype Model of Care

Structure

Shared Governance leverage years of professional experience

Organizational Structures enable decision accountability

360 degree feedback/testingPatients, Families, Care Providers, Community Members, Allied Industries , Volunteers

ProcessesPrototype Model of Care

“Goal: Services should be patient centered and should be pushed to the point of service.” 2008 Transforming Care at the Bedside Initiative (TCAB)

Caregiver workflow redesign to increase patient care time Standardize materials & supplies stock and distribution to elimate

hunting and gathering time Bedside medication administration to increase patient safety

outcomes Linen exchange and distribution to ease supply managment Clinical documentation at appropriate site of care

Processes

ProcessesCaregiver Workflow Assessment

International Nursing Unit Workflow Study

conducted by Dr. Monique Lambert, PI, Intel Digital Health Group

9 Hospitals in US, UK, Singapore

18 different acute units

600 hours of direct observation in total

Documented patterns of clinical work in field notes

Captured clinical work processes using photos and video

Observed clinicians interacting with technology and paper-based systems

Processes

Processes Caregiver Workflow AssessmentMulti-Cognitive vs. Multi-Task Nurse Work Flow : 1 RN, 1Shift

SHIFT CHANGEASSESS PT

PATIENT CRASHASSESS PATIENT

CONSULT WITH MDCHECK /RECORD VITALS

START MED PASSCHART ENTRY

IV WORK CHART ENTRY

COORDINATE UAVITALSCHART

RECEIVE REPORTCONSULT W/ SOCIAL WRK

COORD DISCHARGEORDER FOOD TRAY

COORDINATE UAREMOVE INFUSION PUMP

RECONCILE ORDER TO D/C CATHETERREMOVE CATHETER

CHARTPATIENT COMFORT ADJUST

COORD ORDER FOR NAUSEA MEDSCHECK CATHETER

CHARTADL S

CHART CATHETERNEW LAB ORDERS

ADMIN MEDSGIVE REPORT

LUNCHSPK W PT FAMILY

MEDS, HOME HLTH EDUCIV FLUSH

RECEIVE REPORTIV FLUSH

NEW LABSDISCHARGE PAPERWORK

PAIN MEDS ADMINISTRCHART

RE ASSESS PTDISCHARGE EDUC

DRESSING CHANGECONSULT W SITTER, CRASHING PT

MSG TO IV NURSECHART

LOOK FOR SENSOR OXIMETERSPK W SOCIAL WORKER

CHECK I/O SCHK CHART, NEW ORDER

PICK UP MEDSIV PREP

CHART I S AND O SREVIEW ORDERS

RETRIEVE WIPES FOR PTRETRIEVE COMMODE

PASS MEDSORDER FOOD TRAY

ADL SBREAK

COORD PTPASS MEDS

CHARTREC REPORT

PREP SHIFT REPORTPAGE MD

CALL PT FAMILYCHART

REV PROGRESS NOTESGIVE REPORT

EPISODE

(73)

Nursing workflow is consumed with both cognitive and physical multitask orientation

Multiple tasks with short durations.

Medication administration being one of the largest

Multiple task with multiple interruptions present for potential patient safety issues

Facilities and information system redesign must support nursing workflow in order to improve clinical, service and financial quality

Opportunities exist to re-model care delivery to promote care coordination and critical thinking versus task orientation

Processes Prototype DevelopmentCaregiver Workflow Assessment – Summary of Findings

Processes

10/07/2008Copyright © 2007 McKesson Provider Technologies

Privileged, Proprietary and Confidential. All r ights reserved. 24

9N: Nurse 2

Industry Benchmark : Medications located at bedside can save up to 2 hours of nurse’s time walking back and forth to Med. Room.

Processes Prototype DevelopmentCaregiver Workflow Assessment – Focus on Medication Distribution

Medication Delivery: 1st Shift (8:30 – 9:30am), 1RN

Outcomes What Should be Standardized? Defining the Expectation

Idea Exchange – Cross Industry Discussion of PrototypesPurpose:- Leverage the organization and healthcare community to discuss issues & expectations- Increase awareness of best practice thoughts & ideas in an outside healthcare industry- Validation of findings from research and peer benchmarking

Anticipated Outcome: Performance measures that define success that can establish standard prototypes

Industry Perspectives;

Outcomes

ISSUES OPPORTUNITIES PROGRAM OBJECTIVES

Enh

ance

pat

ient

ex

peri

ence

Red

uce

erro

rs

Impr

ove

Pro

cess

Red

uce

Cos

ts

Gai

n co

mpe

titi

ve

Edg

eIn

corp

orat

e E

vide

nce

Bas

ed

Des

ign

Impr

ove

Safe

ty

Cre

ate

Arc

hety

pe

for

Des

ign

Current State/ Baseline

Future State/ Process Improvement Metric/Target

CLINICAL

Use of Semi-Private Rooms -80% Semi-private beds -20% privates

Increase Private Rooms -80% Semi-private beds -20% privates

X X X X X X X X Improve Pt Satisfaction Scores by 10%; Lower Infection Rates by 5%; Lower ALOS; Reduce Pain Meds, Reduce Pt Falls by 5%; Reduce Medical Errors, Reduce Wrong Pt Errors, Increase Occupancy Rates

OutcomesQuantifying Metrics to Measure Impact

Outcomes

Outcomes Define the Goal, Do Not Adjust to the Consequences

What are the current processes in place?

Which steps are not value added?

Which steps can be combined or automated?

What are the future trends in the OR we will use?

How will this impact the process and staff roles?

Based on the above, how can technologies be leveraged?

How will the facility be designed to support the new realities?

Outcome: Reduce OR case start delays by 50% in the new facility

Outcomes

Outcomes Define the Goal, Do Not Adjust to the Consequences

Outcome: Reduced OR case start delays by 50% yields Virtual Capacity, Financial Savings

Why Does This Matter?

Cost

Annual OR Total Expense $20,000,000

Annual OR Case Volume 9,500

Average Cost/Case $2,105

Average Case Time (incl. room turns) 135 minutes

Average Cost per Minute of OR Time $15

Total Annual Delays 3,100

Average Delay Time (minutes) 16

Annual Cost Impact of Delays $744,000

Cost Savings with 50% Reduction $372,000

In major metro market, $372,000 in savings funds FOUR nursing FTEs annually.

Outcomes

Prototype as Physical Standard;

Department Organization, Key Rooms, Product Specifications

Organizational DiagramsMap Function Programand Relationships

Building Support

• Janitor Closet• Mech/Elec

Building Support

• Janitor Closet• Mech/Elec

Admin Support - Offices

Family / Public SupportWaiting

Dining / VendingConsult

Staff SupportLockerLoungeOn-Call

TeamWork

Consult

Support• Clean• Soiled• Nourish• Med Prep• Equip Store

Multi- purpose

TeamWork

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Private Rooms

TeamWork

Consult

Multi- purpose

TeamWork

Support• Clean• Soiled• Nourish• Med Prep• Equip

Store

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Priv

TeamWork

Consult

Multi- purpose

TeamWork

Support• Clean• Soiled• Nourish• Med Prep• Equip

Store

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Priv

Support• Clean• Soiled• Nourish• Med Prep• Equip Store

Private Rooms Private Rooms

Process SimulatorTest Functional / Behavior Assumptions; Work flow, size and transport time

Four step process:1. Diagram the process2. Add behavioral information3. Run the simulation4. Analyze the results5. Make adjustments

Interactive Gameboarding: Apply Organizational Grid, Test Dependants and Adjacencies

Caption for image

Facility Simulation Modeling Validate Organizational Assumptions

Key Rooms; Private Patient Room Computer Modeling Validate Travel Distance, Site Lines, Clearances, FFE

36Confidential and Proprietary © June 2009 OWP/P

Key Rooms; Private Patient Room Computer Modeling Validate Travel Distance, Site Lines, Clearances, FFE

37Confidential and Proprietary © June 2009 OWP/P

Key Rooms; Private Patient Room Computer Modeling Validate Travel Distance, Site Lines, Clearances, FFE

Physical Testing Creating a Mock Up Center

Physical Testing Creating a Mock Up Center

COSTS: Initial construction cost – carpet: $500,000 less than vinyl sheet 20-year life cost – vinyl flooring: approximately $2 Million less than carpeting

NOISE: Multi-year study Press Ganey patient satisfaction scores on noise: carpet scored same as vinyl APPEARANCE: Vinyl flooring keeps a more consistent, higher level of appearance over life cycle

SUMMARY Cleaning / Labor Costs AFTER 20-yrs/1,000 SF Annual Cleaning / Labor Costs for 110,000 sf Labor Supply

Sheet Vinyl $33,552.74 $184,540.05 $ 77,396.10 $ 107,143.95

Linoleum $28,689.82 $157,793.99 $ 73,391.76 $ 84,402.23

Carpet Tile $40,357.10 $221,964.06 $205,967.11 $15,996.95

Physical Testing Life Cycle Cost AnalysisLIFE CYCLE FLOORING COMPARISON

Product Type Comments Usable Product

Life

Installed Cost Sq.

Ft.

AverageInstalled Cost (per

1,000 sf)

Times Replaced in 20

yrs

Material cost after 20 yrs

Cleaning/Labor Costs after 20 yrs

(per 1,000sf)

Total Costs in 20 Yrs

Wax/Seal Required

PSI

Sheet Vinyl heat welded

Requires some finish

20 years

$5.25 $5,250. 0 $5,250. $33,552.74 $38,802.74 Yes 750m

Sheet VinylWood look heat welded

Requires some finish

20 years

$7.00 $7,000. 0 $7,000 $33,552.74 $40,552.74 Yes 700m

Linoleumwelded

Requires some finish (depending

on installation)

20 years

$5.25 $5,250. 0 $5.250 $28,689.82 $33,939.82 Some 400m

Carpet Tile Ease of replacemen

t

5 years $5.00 $5,000. 3 $15,000. $40,357.10 $55,357.10 n/a n/a

Physical Testing Creating a Mock Up Center

Physical Testing Creating a Mock Up Center

Mock Up Testing Results Survey Clinician, Patients, Families, Community• Patient Unit Prototype Comments • Private room ~ staff connections • Response to family needs• Continuous handrails to toilet room• Concern for privacy with charting

windows• Concern about acoustics/noise

control• Flooring analysis: ergonomics,

acoustics, rolling resistance, maintenance

• Furniture analysis: chair, recliner, overnight accommodations

• Hand wash sink access• Medication drawer locations

Prototype Results1. Strategic Impact

Increased from the 35th to the 81st percentile in “Likelihood to Recommend” from

Quarter 1 2010 to Quarter 1 2011. (December 2011 patient satisfaction was at the 99th percentile).

Growth in OB / GYN, Physician recruitment increased by 45%.

200% Growth in neonatal care program and achieved Level III Nursery status.

Growth in PSA and SSA market in competitive region offering elevated inpatient environments. 5.5% increase in discharges from FY 2010 to FY 2011.

Created market differentiation with outdoor therapeutic service on Units.

Pilot Horticultural Therapy Program – Proprietary Services offering in the region.

Exterior balcony utilization: Averaging 270 visitors / month per unit.

Nursing “Job Enjoyment” as measured by NDNQI is above the national mean (Oct. 2010).

Prototype Results2. Operational Impact

Elimination of thru room Nurse Servers.

First cost savings of $460,000 (millwork).

Mitigate historic 11-18% loss of inventory .

Decentralize medication distribution to the bedside (TCAB)

Mitigate infection control risk. (Savings +/-$11,000/blood infection).

Patient safety standardization. (Mitigate falls, decreased by 17%).

Greater adoption of clinical documentation at the bedside which promotes improvements in care coordination and communication. (Patient Satisfaction due to

increase increased patient-nurse face time).

Inventory cost control for non-chargeable due to consolidated organizational model.

Private Accommodations = 50% increase in square foot area with no FTE increase.

(All nursing staffing is within the 75% performance quartile as measured by Deloitte).

3. First Cost/Facility Impact Elimination of double door access to patient room

Net savings of $400,000.00 Flooring product testing and selection yielded 15-year lower life-cycle cost Private patient rooms resulted in higher patient utilization rates from 64% to

86% in first 6 months Energy savings forecast in first year operations of $380,000 Speed to market fabrication of prototype room components advanced

project completion 3.5 months ahead of schedule ~ patient revenue of $6.4M contribution

Prototype Results

40% reduction in baseline required FTEs per Adjusted Patient Discharge as modified for Case Mix Index

50% decrease from baseline aggregated clinical procedure cycle times

30% decrease from baseline area per Adjusted Patient Discharge as modified for Case Mix Index

50% decrease from baseline for time to build

25% decrease in natural resource use per APD

Ongoing Prototype Research

Bibliography• June A. Schmele, RN, Ph.D.;   Quality Management in Nursing and Health Care. 1996.  Quality in Practice.

Albany. Delmar Publishers.

• Patricia S. Schroeder, MSN, RN; Regina M. Maibusch, SSSF, MS, RN; A Unit-Based Approach. 1984.  Nursing Quality Assurance: Rockville, Maryland. An Aspen Publication.

• Avedis Donebedian, MD; Measuring and Developing Hospital and Medical Care. (1976) Bulletin New York Academy of Medicine; 52(1), 51- 59.

• Avedis Donebedian, MD, MPH; The Quality of Care; How Can It Be Assessed?. JAMA September 23/30. 1988:260(12); 1743-1748.

• Monique Lambert, PhD, PI, Intel Corporation, Third Annual Nursing Leadership Congress “Designing Frameworks for Patient Safety” Conference Proceedings, Journal of Patient Safety 4(2):54-60, June 2008.

• “How Shadowing Shaped the Design of the Mobile Clinical Assistant” Intel Software Insight, Issue 12:16-17, 2007.

• “PHAMA Patient Handling and Movement Assessments: A White Paper” 2010 Health Guidelines Revision Committee Specialty Subcommittee on Patient Movement, The Facility Guidelines Institute 2010

Thank You.FOR MORE INFORMATION PLEASE CONTACT:

Jocelyn StroupeCannon [email protected]

Dale BeattyNorthwest Community [email protected]

Deborah SheehanCannon [email protected]

Charlie StevensonNorthwest Community [email protected]